Nevada Health Exchange

Establishing the Exchange

On June 16, 2011, Nevada’s Governor Brian Sandoval (R) signed SB 440 into law establishing the Silver State Health Insurance Exchange. In March 2013, the state announced that the online marketplace would be called Nevada Health Link.

Structure: The legislation defines Nevada’s Exchange as a quasi-governmental organization.

Governance: The Exchange is governed by a 10-member board, including three ex officio, non-voting members (or their designees): the Director of the Department of Health and Human Services, the Director of the Department of Business and Industry, and the Director of the Department of Administration. The Governor will appoint five of the voting members, while the Senate Majority Leader and the Speaker of the Assembly will each appoint one voting member. The legislation specifies that voting members should possess subject expertise in areas such as: individual or small employer health insurance markets; health care administration, financing, or information technology; health care delivery system administration; or experience of consumers that would benefit from the Exchange. Voting members cannot be Legislators or hold an elected office in Nevada state government, nor can they be affiliated with, have ownership interest in, or be a representative of a health insurer.

On September 23, 2011, the final board members were appointed. The voting members are:

Lynn Etkins, Legal Aid Center of Southern Nevada

Dr. Judith Ford, Canyon Gate Medical Group

Leslie Ann Johnstone, Health Services Coalition

Marie Martin Kerr, Kerr Intellectual Property Law Group

Dr. Ronald Kline, Comprehensive Cancer Centers of Nevada

Elsie Lavonne Lewis, Clark County Urban League

Barbara Smith Campbell, Consensus

The Exchange Board hired an Executive Director in December 2011.

The Board submitted three reports to the Governor and the Legislature in December 2011, including, a fiscal and operational report, a report for the public summarizing the activities of the Board, and an adopted plan for the implementation and operation of the Exchange. The Board is required to submit fiscal and operational reports to the Governor and legislature by June 30 and December 31 of each year.

The Board has established five advisory committees to provide recommendations on Exchange implementation in the following areas: finance and sustainability; plan certification and management; Small Business Health Options Program (SHOP) Exchange; reinsurance and risk adjustment programs; and consumer assistance. The Advisory Committees met regularly starting in March 2012, and the Board approved 35 of their recommendations. As of May 2013, the Advisory Committees will no longer meet.

The Exchange Board completed a Tribal Interaction and Impact Assessment and is using the information to reach out to the state’s Tribes. The Exchange has also signed a Tribal consultation agreement with the Indian Health Board of Nevada.

Contracting with Plans: In April 2012, the Exchange Board approved guiding principles recommended by the Plan Certification and Management Advisory Committee, which included adopting a “Free Market Facilitator” model that “ensures the maximum participation by insurers and the widest choice for consumers.” In September 2012, the Board approved allowing carriers to offer Qualified Health Plans (QHPs) in either or both the Individual and SHOP Exchanges at their discretion and that QHPs not be required to be identical in each Exchange. Carriers are required to offer one silver level plan and one gold level plan in the Exchange, and silver level plans must offer cost-sharing variations of 73%, 87%, and 94% actuarial value. Carriers must also offer a zero cost-sharing version of all plans for American Indians as well as child-only plans at the same level of coverage as any other plan offered through the Exchange. Catastrophic plans may only be offered in the individual market and to individuals under the age of 30 or to individuals with a certification for hardship exemption in effect. Also, each licensed carrier may not offer more than five QHPs in each metal tier (including a catastrophic tier) in each Exchange.

Carriers must be accredited by the National Committee for Quality Assurance (NCQA), the Utilization Review Accreditation Commission (URAC), or another recognized accreditation agency in order to submit QHPs for review by the Division of Insurance (DOI). Carriers will use the standard data templates used by the Department of Health and Human Services (HHS) in the federally-facilitated exchange to submit rate and form filing information for QHPs through the System for Electronic Rate and Form Filing (SERFF). QHP submissions must be completed by early July, and the DOI expects to review and certify QHPs by early August. Individual market QHPs will be in place for one year and changes to plans may only be made prior to the open enrollment period. The Exchange is hosting a series of eleven carrier onboarding meetings to detail Exchange requirements and to provide carriers with a forum to ask questions about the onboarding process.

In April 2013, the Board approved network adequacy standards that require carriers to ensure sufficient numbers and types of providers to meet the needs of the enrolled population, to comply with the Affordable Care Act’s Essential Community Provider requirement, and to include at least one community hospital in the provider network, if available. The Board established network adequacy ratios and travel standards according to county and provider specialty. Carriers may employ telemedicine to meet these accessibility requirements. Carriers must make their provider directories available to the Exchange for publication online and to enrollees in hard copy, if requested.

Risk Adjustment, Reinsurance, and Risk Corridors: The Board approved plans to conduct an analysis to determine whether Nevada-specific factors should be used in a risk adjustment model and continues to discuss whether the state should administer the reinsurance program or defer to the federal government.

Dental and Vision Benefits: In March 2013, the Board decided that all QHPs that provide the pediatric dental essential health benefit must submit the dental benefit as a rider for the product. In April, however, the Centers for Medicare and Medicaid Services (CMS) determined it would not recognize riders for the pediatric dental essential health benefit. The Plan Certification and Management Advisory Committee met twice in May and ultimately recommended that the Exchange allow the pediatric dental benefit to be embedded in a QHP, bundled with a QHP, or sold as a stand-alone plan. All children enrolled in a QHP through Nevada Health Link must purchase the pediatric EHB. Annual out-of-pocket maximums will be limited to $700 for one child and $1,400 for two or more children enrolled in stand-alone plans.

Consumer Assistance and Outreach: In December 2012, the Board approved a Navigators, Enrollment Assisters, Certified Application Counselors (CACs), and Producers Plan, detailing how the four entities will work together to enroll eligible individuals through Nevada Health Link. The primary function of Navigators will be to provide enrollment assistance and educational outreach, while Assisters will focus solely on application and enrollment assistance. Certified Application Counselors (CACs) will provide enrollment assistance and will largely work in hospitals. CACs will not be compensated by the Exchange. Navigators, Enrollment Assisters, and CACs must receive Exchange Enrollment Facilitator (EEF) Certification from the DOI prior to enrolling individuals or employers in a QHP. EEF training and testing requirements will be developed by the DOI in partnership with the Exchange. The Exchange released a Request for Applications (RFA) for Navigator and Enrollment Assisters in March 2013 and received 41 applications. In June 2013, Nevada Health Link announced the eight organizations that have been selected as Exchange Enrollment Facilitator grantees.

In order to sell insurance products through the Exchange, producers must register with the Exchange, fulfill training and testing requirements, and satisfy the Exchange’s privacy and security standards. Producers will not be compensated by the Exchange but will continue to receive compensation from carriers, in the same or similar manner as is done today in Nevada. The Board approved a recommendation that web-brokers will not be able to sell QHPs and access Advanced Premium Tax Credit and Cost Sharing reductions through their portals.

The state released an RFP in September 2012 for help planning a marketing and branding campaign in English and Spanish for the Exchange, and in January 2013 entered into a contract with a vendor. The campaign is broken out into three phases: Exchange branding, education, and call to action. In March 2013, the Board approved Nevada Health Link as the Exchange’s brand name and in April approved the logo, color palettes, and taglines. In June 2013, Nevada Health Link launched a website for consumers, including a subsidy calculator.

The media campaign launched July 1 and uses a mix of mediums to reach target audiences, including television, radio, print, and digital media. Nevada Health Link awareness advertising will run from July 2013 through March 2014, with three distinct waves of messaging. The second phase also includes an outreach component that will have a person-to-person, grassroots focus. Nevada Health Link will partner with non-profit, state-based, and school-based organizations throughout the state to have a presence at 70 events through September 30. The objective of the campaign’s second and third phases is to generate 85% awareness of the Exchange among target audiences and facilitate the enrollment of 118,000 Nevadans through Nevada Health Link. Target audiences are Hispanics, families with children, and male young adults with incomes between 138-400% FPL. The state has also outsourced the development of an Exchange call center.

Small Business Health Options Program (SHOP) Exchange: In April 2012, the Exchange Board approved guiding principles recommended by the SHOP Advisory Committee. In September 2012, the Board approved keeping the Individual and SHOP markets separate, as well as keeping the market for small groups (1-50) and mid-sized groups (51-100) separate until they have to be merged in 2016. The Exchange’s certification requirements for QHPS in the Individual and SHOP Exchanges will be the same.

The Committee has also begun exploring issues surrounding employer and employee choice in the SHOP Exchange. The SHOP Exchange will offer three options to employers. The ‘Open SHOP’ option allows an employee to access all SHOP QHPs. The ‘Open Metal Tier’ option will allow an employer to select a specific metal tier for his/her employees. The ‘Package Option’ will let an employer select a specific package for his/her employees. Employers must contribute at least 50% of premiums for the lowest cost QHP available to employees. The minimum employee participation rate is 75%.
Information Technology (IT): Through the use of a subcontractor, the Nevada Health Care Reform Unit within the Department of Health and Humans Services completed an IT gap analysis of existing systems that could be used to support the Exchange, as well as completed the preliminary design and requirements for a new eligibility engine. Nevada currently operates two separate eligibility systems for Medicaid and the Children’s Health Insurance Program (CHIP) and the state plans to develop a streamlined single application. A Request for Proposals released by the Nevada Department of Health and Human Services is soliciting subcontractors for the “Health Care Reform Eligibility Engine” to determine eligibility for Medicaid, CHIP, and subsidized coverage through the Exchange. The subcontractor will develop and implement a business rules engine that will store all of the eligibility rules for the State’s publicly-subsidized health coverage programs in a single location and make it accessible to individuals shopping for coverage from multiple entry points.

In July 2012, the Exchange awarded a contract for Business Operations Services that would provide end–to-end business needs for the Exchange through December 31, 2016.The subcontractor will be responsible for building the IT infrastructure necessary for the Exchange and for implementing a Call Center to provide assistance to individuals enrolling in coverage. The state expects development and implementation of the IT Solution and a Call Center by October 1, 2013, followed by three years of operations, maintenance, and enhancements. The Board also awarded an Independent Validation and Verification services contract through January 2014.

Financing: In March 2012, the Finance and Sustainability Committee released financing options for the Exchange that recommended assessing fees on either qualified health plans (QHP) in the Exchange or on all plans offered in the individual and small group market, suggested a gradual increase in the QHP enrollment fee, and recommended charging fees to dental, vision and Medicare products. While the Finance and Sustainability Committee continues to work on broader financing options, in May 2012, the Board approved a recommendation by the Committee to raise supplemental revenue for the Exchange by charging user fees to stand-alone vision and dental products and by offering web advertising on the site. The following month the Board approved exempting insurers from being taxed on fees charged by the Exchange. The Board also rejected a proposal by the Committee to use a General Fund appropriation as a supplementary source of Exchange revenue by subsidizing individuals’ enrollment fees. In January 2013, the Board adopted a regulation establishing a monthly fee charged to insurers for each member enrolled in the insurer’s plans. The Exchange established separate fees for QHPs that do not include a dental component, QHPs that include dental, and stand-alone dental plans.

Essential Health Benefits (EHB): The Affordable Care Act requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through the Exchange, cover certain defined health benefits. States must decide whether to benchmark their EHB plan to one of ten plans operating in the state or default to the largest small-group plan in the state. On December 14, 2012, the Insurance Commissioner announced the selection of Health Plan of Nevada POS C-XV-500-HCR as the EHB benchmark plan, the Children’s Health Insurance Plan (CHIP) as the pediatric dental supplement, and the Federal Employee Vision Plan (FEDVIP) as the pediatric vision supplement.

Exchange Funding

In September 2010, the Nevada State Department of Health and Human Services received a federal Exchange Planning grant of $1 million. The Department has since received four federal Level One Establishment grants: $4 million in August 2011, $15.3 million in February 2012, $4.4 million in May 2012, and $9 million in July 2013. The grants will be used to develop a rules-based eligibility engine that will serve as the single, streamlined eligibility process for all medical assistance programs in the state, to support information technology security requirements, and to fund training for EEFs. In August 2012, the state received a federal Level Two Establishment grant for $50 million; this will fund Exchange operations through December 2014.

Next Steps

On January 3, 2013, Nevada received conditional approval from the U.S. Department of Health and Human Services (HHS) to establish a state-based exchange. Final approval is contingent upon the state demonstrating its ability to perform all required Exchange activities on time, complying with future guidance and regulations, and demonstrating its capacity to administer Exchange plan management functions.